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Foot Pain

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of foot pain.

Alternative Names

Bunions; Corns; Hammertoe; Plantar Fasciitis

Heel Pain

The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects two million Americans every year. It can occur in the front, back, or bottom of the heel. General treatment guidelines are follows:

  • The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after eight weeks.
  • If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy.
  • Heel surgery to relieve pain may be performed for heel spurs, plantar fasciitis, bursitis, or neuroma.
  • Surgery is not recommended until nonsurgical methods have failed for at least six months and preferably up to 12 months. Nonsurgical treatments for heel pain are effective in 90% of patients.

Plantar Fasciitis and Heel Spur Syndrome

Plantar Fasciitis and Heel Spurs. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps to serve as a shock absorber for the body. The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch. The condition can be temporary or may become chronic if the problem is ignored. In such cases, resting provides relief, but only temporarily.

Heel spurs are calcium deposits that can develop under the heel bone as result of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.

Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports and accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.

Treatment Goals. The three major treatment goals for plantar fasciitis are:

  • Reducing inflammation and pain.
  • Reducing pressure on the heel.
  • Restoring strength and flexibility.

Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed reduces the risk for future surgery. Pain that is not relieved by NSAIDs may require more intensive treatments, including leg supports and even surgery.

Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:

  • Put the hands on a wall and lean against them.
  • Place the uninjured foot on the floor in front of the injured foot. The injured foot in back should have the heel off the floor.
  • Stretch the back leg and foot gently.

With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.

Medications to Relieve Pain and Reduce Inflammation.

  • NSAIDs. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil).
  • Corticosteroids. Corticosteroids, or steroids, are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relieve in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foots tissue using an electrical current.

Reducing Pressure on the Heel. A number of approaches can relieve pressure on the heel.

  • Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support to the rest of the heel while relieving pressure on the painful spot itself. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics. A 2001 study indicated, however, that patients may comply better with the custom-made orthotics.
  • Night Splints. There is some evidence that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients. A 2001 comparison study reported, however, that patient compliance was better with custom-made prescribed orthotics than with tension night splints and that there was no difference between the two in pain improvement. Still, splints should be tried first
  • Elevated Heels. Some people report that mild symptoms may be relieved with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate to severe condition. (Heel cups have not been proven to be very useful.)

Extracorporeal Shock Wave Therapy. Researchers are investigating benefits of extracorporeal shock wave therapy (ESWT). The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which triggers healing of the tissues that are causing the pain. Studies typically employ three treatments of low-energy shock waves given once a week. A few studies have reported significantly reduced pain after the treatment compared to sham treatments. It appears to take at least three weeks for the benefits to become evident. (In a study on the use of ESWT for heel spurs it took several months for the condition to improve after the procedure.) ESWTs benefit has been demonstrated in the shoulder where calcification has occurred, and is being investigated for plantar fascitis. Several studies, including a 2004 survey of 800 patients, show benefit, but a major study in 2003 did not find any benefits compared to sham therapy. More research is needed to determine if this approach has any value.

Surgery. Surgery is appropriate in about 5% of patients, typically those who have disabling heel pain for at least a year that does not respond to other treatments. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia.

The standard procedure uses a large incision and takes about two months to resume complete normal activity. A less invasive variant uses a procedure called endoscopy that employs small incisions and is proving to be effective.

For either approach, some studies report good to excellent pain relief in 80% to 90% of patients. In one study, however, half of the patients were dissatisfied because the procedure didnt work or because recovery took too long. In another 2000 study, about 15% of the patients reported long-lasting complications, including pain from scar tissue and continued heel pain. Pain is more likely when more than half of the plantar fascia was released during surgery.

Wearing a below-the-knee walking cast after the operation for two weeks may reduce the need for pain relief and speed recovery time compared to use of crutches.

Bursitis of the Heel

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid, beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.

Haglunds Deformity

Haglunds deformity, known medically as posterior calcaneal exotosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it frequently occurs with high heels. (It can also develop in runners, however.)

Treatment for Haglunds Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) will also reduce pain. Physicians may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for over 30% of patients and, in fact, 14% experienced a worse condition afterward. A more recent study reported that surgery cured 90% of cases, but full recovery required six months to two years. Experts advise patients to try all conservative measures before choosing surgery.

Achilles Tendinitis

Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury and is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.

Inflammed achilles tendon
An inflammed or torn achilles tendon causes intense pain and affects mobility.

People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and tend to bounce when they walk. A shortened tendon can be due to an inborn structural abnormality or acquired after wearing high heels regularly.

Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches are discussed.

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) may help to ease pain and reduce inflammation. It is also helpful to apply ice four or five times a day for 20 to 30 minutes. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much and they pose a risk for rupture of the tendon.)

Gentle Stretching. Gentle stretches may also help reduce the pain and spasms. If the calf is swollen, elevating the leg is recommended. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.

Surgery vs. Nonsurgical Treatment. If pain continues, the ruptured tendon will require a cast and perhaps surgery. Although some experts believe a cast is sufficient in many cases, without an operation, the tendon has a 38% chance of rupturing again. Some experts suggest surgery for active persons and nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization that can average six weeks. Complications can include a significant surgical scar, infection, and muscle atrophy. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about five days and fitted with special footgear (Variostabil that continuously raised the back of the foot). The footgear was effective for most patients and the tendon ruptured again in only 5% of these cases.

Excessive Pronation

Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.

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